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Jurisdiction B Connections June 2016

The Jurisdiction B Durable Medical Equipment Medicare Administrative Contractor (DME MAC) processes durable medical equipment, prosthetics, orthotics and supplies (DMEPOS) claims for beneficiaries who reside in the states of Illinois, Indiana, Kentucky, Michigan, Minnesota, Ohio and Wisconsin.

The Jurisdiction B Connections is published quarterly in March, June, September and December.

To receive up-to-date information about Medicare and/or changes within the Jurisdiction B Durable Medical Equipment Medicare Administrative Contractor (DME MAC), National Government Services, Inc. encourages suppliers to sign up for the electronic mailing list, Jurisdiction B DME Email Updates.

CMS Quarterly Provider Update The Centers for Medicare & Medicaid Services (CMS) publishes the Quarterly Provider Update (QPU) at the beginning of each quarter to inform providers and suppliers about the following:

• Regulations and major policies under development during the quarter • Regulations and major policies completed or cancelled • New or revised manual instructions

Think Green and Go Paperless Suppliers should file claims electronically and you are encouraged to sign up for both the electronic remittance advice (ERA) and electronic funds transfer (EFT) to take advantage of the tremendous benefits associated with electronic transactions.

Special Edition of the DME MAC Jurisdiction B Insider CGS has produced a special edition of the DME MAC Jurisdiction B Insider supplier publication. The special edition provides important information on:

• Jurisdiction B cutover dates • New addresses, telephone and fax numbers for CGS Jurisdiction B • Updates from the Medical Review department • News and instructions from CEDI regarding contractor number changes • Jurisdiction B website tools and services crosswalk • Jurisdiction B myCGS new user instructions and education • EIDM registration updates • New Jurisdiction B supplier manual information and more!

Read the DME MAC Jurisdiction B Insider Implementation Special Edition located at http://cgsmedicare.com/jb/pubs/insider/2016_insider_se.pdf.

http://www.wcmwidgets.com/ngs/poc/ngsmedicare?uri=wcm:path:&page=Z6_4AIE11C0K8TRC0AKMLVUI830N2&LOB=DME&LOC=All%20States&ngsLOC=All%20States&ngsLOB=DME&jurisdiction=Jurisdiction%20Bhttp://www.cms.gov/Regulations-and-Guidance/Regulations-and-Policies/QuarterlyProviderUpdates/index.html?redirect=/QuarterlyProviderUpdates/http://www.ngsmedicare.com/ngs/poc/ngsmedicare?1dmy&urile=wcm%3apath%3a%2FNGSMedicareContentNEW%2FNGSMedicareNEW%2FElectronic%2BData%2BInterchange%2FElectronic%2BData%2BInterchange%2FTask%2B4_DME&LOB=DME&LOC=All%20States&ngsLOC=All%20States&ngsLOB=DME&jurisdiction=Jurisdiction%20Bhttp://www.ngsmedicare.com/ngs/poc/ngsmedicare?1dmy&urile=wcm%3apath%3a%2FNGSMedicareContentNEW%2FNGSMedicareNEW%2FElectronic%2BData%2BInterchange%2FElectronic%2BData%2BInterchange%2FTask%2B4_DME&LOB=DME&LOC=All%20States&ngsLOC=All%20States&ngsLOB=DME&jurisdiction=Jurisdiction%20Bhttp://www.ngsmedicare.com/ngs/poc/ngsmedicare?1dmy&urile=wcm%3apath%3a%2FNGSMedicareContentNEW%2FNGSMedicareNEW%2FElectronic%2BData%2BInterchange%2FElectronic%2BData%2BInterchange%2FHow%2BDo%2BI%2BSign%2BUp%2BFor%2BEFTs_DME&LOB=DME&LOC=All%20States&ngsLOC=All%20States&ngsLOB=DME&jurisdiction=Jurisdiction%20Bhttp://cgsmedicare.com/jb/pubs/insider/2016_insider_se.pdfhttp://www.cgsmedicare.com/jb/index.html

June 2016 Jurisdiction B Connections 2

Your Feedback Matters. Take the 2016 MAC Satisfaction Indicator Survey Today! Your feedback matters. It is what drives change to your experience on NGSMedicare.com and allows us to learn about your favorite features.

Share your opinion with the Centers for Medicare & Medicare Services (CMS) by participating in the 2016 Medicare Administrative Contractor Satisfaction Indicator (MSI) survey. This quick ten-minute survey is your opportunity to share your experience with the services we provide. We appreciate your willingness to participate and assure you your responses will be kept completely confidential.

Click here to take the 2016 Jurisdiction B MSI Survey

If you experience technical difficulties accessing or submitting the survey, please contact CFI Support at [email protected].

In This Issue

Medicare Information for All Suppliers COVERAGE, BILLING AND DENIALS 5 Unappealable Claims Returned as Unprocessable ...................................................................................... 5 Correct Coding – JW Modifier Use – Revised – Effective for Claims with Dates of Service On or After 7/1/2016 .................................................................................................................................... 5 Medicare Record Authentication – Tips for Physicians – Updated ............................................................... 6 Appropriate Usage of the EX Modifier .......................................................................................................... 8 First Quarter 2016 Top Claim Submission Errors ......................................................................................... 8 FEE SCHEDULE, PRICING AND OVERPAYMENTS New Extended Repayment Schedule – Voluntary Underpayment Form .................................................... 13 Hassle-Free Timesaver – Submit Immediate Recoupment Requests Online ............................................. 13 MEDICAL POLICY Local Coverage Determination and Policy Article Revisions Summary for 5/19/2016 ................................ 14 Local Coverage Determinations and Policy Article Revisions Summary for 3/3/2016 ................................ 15 Local Coverage Determination and Policy Article Revisions Summary for 3/17/2016 ................................ 19 MISCELLANEOUS SUPPLIER INFORMATION CMS Website Links ................................................................................................................................... 19 Round 2 Recompete and National Mail-Order Recompete Contract Suppliers Announced ....................... 19 Comprehensive Error Rate Testing Documentation Contractor Updates ................................................... 20 Comprehensive Error Rate Testing High Error Audit – First Quarter 2016 Widespread Prepayment Review Update ...................................................................................................................... 20 Notice of New Interest Rates for Medicare Overpayments and Underpayments – Change Request 9644 ............................................................................................................................... 22 Comprehensive Error Rate Testing High-Error Audit – Fourth Quarter 2015 Widespread Prepayment Review Update .................................................................................................. 23 First Quarter 2016 Supplier Telephone Inquiries ....................................................................................... 25 First Quarter 2016 Supplier Written Inquiries ............................................................................................. 28

https://urldefense.proofpoint.com/v2/url?u=http-3A__click.email.ngsmedicare.com_-3Fqs-3D4131bb880711c24bcdeb7ed2c5340786f3efaafc535897162fdaf9712c90362e&d=CwMCAg&c=A-GX6P9ovB1qTBp7iQve2Q&r=B2xE4LbqQXHLyNepi-SAPFy_uwFncPQEIucskpUZsh4&m=HPnPRadL-7qFExgRHhxFn8L8b2GQOtAbLT-Wcdj2rvQ&s=YoKNg7VgUbIdF-KxmoR7f_Vc8DmS0Rpd1EoTfmeMUMM&e=mailto:[email protected]


Self-Service NGSMedicare.com – Jurisdiction B DME Page Expiring 6/30/2016 ........................................................... 32 Where Are My Medicare University Credits? ............................................................................................. 32 Archiving Medicare University Courses ..................................................................................................... 32

Drugs/Infusion/Parenteral and Enteral Nutrition and Infusion INFUSION Correct Coding Reminder – Duopa® (AbbVie) ........................................................................................... 33 Billing for External Infusion Pumps and Drugs When Treatment Was Initiated Somewhere Other Than the Beneficiary’s Home ..................................................................................................................... 34 PARENTERAL AND ENTERAL NUTRITION Enteral Nutrition – First Quarter 2016 Widespread Prepayment Review Update........................................ 35 Enteral Nutrition – Fourth Quarter 2015 Widespread Prepayment Review Update .................................... 36

Mobility/Respiratory MOBILITY Correct Coding – Manual Wheelchair Bases – Revised ............................................................................. 37 Manual Wheelchair Service Edit – First Quarter 2016 Widespread Prepayment Review Update ............... 38 Power Mobility Devices – K0816 Widespread Prepayment Probe Review Update .................................... 39 RESPIRATORY Oxygen and Oxygen Equipment – First Quarter 2016 Widespread Prepayment Review Update ............... 40 Positive Airway Pressure Devices for the Treatment of Obstructive Sleep Apnea – First Quarter 2016 Widespread Prepayment Review Update ..................................................................... 41 Positive Airway Pressure Devices for the Treatment of Obstructive Sleep Apnea – Fourth Quarter 2015 Widespread Prepayment Review Update ................................................................. 42

Other Durable Medical Equipment Correct Coding and Coverage of Ventilators – Revised May 2016 ............................................................ 44 Pressure Reducing Support Surfaces – Group 2 – First Quarter 2016 Widespread Prepayment Review Update ...................................................................................................................... 46 Pressure Reducing Support Surfaces – Group 2 – Fourth Quarter 2015 Widespread Prepayment Review Update ...................................................................................................................... 47 Vacuum Erection Devices – Third Quarter 2015, Fourth Quarter 2015 and First Quarter 2016 Widespread Prepayment Review Update .................................................................................................. 48 Seat Lift Mechanisms – First Quarter 2016 Widespread Prepayment Review Update ............................... 49 Hospital Beds and Accessories – First Quarter 2016 Widespread Prepayment Review Update ................ 50

Orthotics and Prosthetics/Therapeutic Shoes/Lenses ORTHOTICS AND PROSTHETICS Spinal Orthoses – First Quarter 2016 Widespread Prepayment Review Update ........................................ 52 Spinal Orthoses – Fourth Quarter 2015 Widespread Prepayment Review Update .................................... 53 Hand-Finger Orthoses (L3923) – Use of CG Modifier – Revised ............................................................... 54 Correct Coding – Martin Bionics Socket-less Socket™ .............................................................................. 54 Correct Coding – LIM innovations Infinite Socket™ – Revised .................................................................. 55 Correct Coding – Powered Exoskeleton Products ..................................................................................... 57


THERAPEUTIC SHOES Frequently Asked Questions – Therapeutic Shoes for Persons with Diabetes ........................................... 57 Surgical Dressings/Glucose Monitors/Urological and Ostomy Supplies/Other Supplies ............................. 60 Surgical Dressings ..................................................................................................................................... 60 Surgical Dressing Widespread Prepayment Probe Review –Foam Update ............................................... 60 GLUCOSE MONITORS Glucose Monitors –First Quarter 2016 Widespread Prepayment Review (A4253) Update ......................... 61 Glucose Monitors – First Quarter 2016 Widespread Prepayment Review (A4253KX) Update ................... 62 Glucose Monitors With Integrated Voice Synthesizers – First Quarter Widespread Prepayment Targeted Medical Review Update .............................................................................................................. 63 Glucose Monitors – Fourth Quarter 2015 Widespread Prepayment Review Update .................................. 64 Widespread Prepayment Probe Review Update Glucose Testing Supplies – Date Span Overutilization ... 65 Glucose Monitors With Integrated Voice Synthesizers – Widespread Prepayment Targeted Medical Review Update .............................................................................................................. 66 Glucose Monitors (L27231) – Fourth Quarter 2015 Prepayment Review (A4253KX) Update .................... 68 UROLOGICAL AND OSTOMY SUPPLIES Urological Supplies – First Quarter 2016 Widespread Prepayment Review Update ................................... 69 Urological Supplies – Fourth Quarter 2015 Widespread Prepayment Review Update ............................... 70

Jurisdiction B DME Contact Information ............................................................................................................................................................ 72

Supplemental Resources MLN Connects Provider eNews ................................................................................................................. 75 Medicare Learning Network Matters Articles .............................................................................................. 75

Jurisdiction B Tip of the Week Items Requiring a Durable Medical Equipment Information Form .............................................................. 76 Preventing Frequency Denials on Orthotics and Supplies ......................................................................... 76 Beneficiary Signature Requirements for Proof of Delivery ......................................................................... 77 Beneficiary Signature Requirements for Assignment of Benefits ............................................................... 78 Beneficiary Signature Requirements for ABN ............................................................................................ 78 Failure to Meet Continued Coverage Requirements for Positive Airway Pressure Devices ........................ 79 Phase II Enhancements to IVR for Same and Similar Functionality A, L and V Codes .............................. 80 Resolving Denials Due to ADR Nonresponse ............................................................................................ 81 Billing Reminder: Appropriate Usage of the EX Modifier ............................................................................ 81 MAC Satisfaction Indicator Now Available ................................................................................................. 82


Medicare Information for All Suppliers

COVERAGE, BILLING AND DENIALS Unappealable Claims Returned as Unprocessable Claims may be returned as unprocessable with American National Standard Institute (ANSI) code 16 or 4 due to missing or invalid information. Claims may also be returned as unprocessable with ANSI code 234 when you bill for items that are not separately payable. Some examples of these denials include, but are not limited to: invalid National Provider Identifier (NPI) or missing required information such diagnosis pointer, Healthcare Common Procedure Coding System (HCPCS) code, or modifier. We have seen an increase in suppliers submitting appeals for these types of denials. Claims returned as unprocessable do not have appeal or reopening rights because an initial determination could not be made without all of the required information. When you receive an ANSI 16 or 4 denial, you must make the necessary corrections and resubmit your claim. When you receive an ANSI 234, the item is not separately payable and has no appeal rights. If you submit an appeal or a reopening, your request will be sent back via a letter advising we are unable to process your request. It is imperative when submitting claims that your claim is accurate, complete with all necessary information.

For more information, visit Chapter 12 of the Jurisdiction B Supplier Manual and the Claim Submission Articles page on our website.

Correct Coding – JW Modifier Use – Revised – Effective for Claims with Dates of Service On or After 7/1/2016 Joint DME MAC Publication

Originally Published 5/4/2016

The Centers for Medicare & Medicaid Services (CMS) recently issued updated guidance on the billing of drug wastage to REQUIRE use of the JW modifier (drug amount discarded/not administered to any patient). For the Durable Medical Equipment Medicare Administrative Contractors (DME MACs), the JW modifier only applies to the following local coverage determinations (LCDs):

• External infusion pumps • Intravenous immunoglobulin (IVIG) • Nebulizers

These LCDs will be updated to include the JW modifier requirements. Required use of the JW modifier is effective for claims with dates of service (DOS) on or after 7/1/2016.

The CMS Internet-Only Manual Publication 100-04, Medicare Claims Processing Manual, Chapter 17, Section 40 contains information on the use of the JW modifier for discarded drugs and biologicals. The Medicare Program provides payment for the amount of a single use vial or other single use package of drug or biological discarded, in addition to the dose administered, up to the amount of the drug or biological. There are two scenarios that can occur:

Scenario 1 When the Healthcare Common Procedure Coding System (HCPCS) code unit of service (UOS) is less than the drug quantity contained in the single use vial or single dose package, the following applies:

https://www.ngsmedicare.com/ngs/poc/ngsmedicare?1dmy&urile=wcm%3apath%3a%2FNGSMedicareContentNEW%2FNGSMedicareNEW%2FPublications%2FManuals%2FSupplierManual%2FChapter%2B12%2B-%2BClaim%2BSubmission%2FAcceptable%2BClaim%2BFormats&LOB=DME&LOC=All%20States&ngsLOC=All%20States&ngsLOB=DME&jurisdiction=Jurisdiction%20Bhttps://www.ngsmedicare.com/ngs/poc/ngsmedicare?1dmy&urile=wcm%3apath%3a%2FNGSMedicareContentNEW%2FNGSMedicareNEW%2FClaim%2BSubmission%2BArticles%2Band%2BModifier%2BTips%2FClaim%2BSubmission%2F2011%2BHCPCS%2BCode%2BUpdate_Revised&LOB=DME&LOC=All%20States&ngsLOC=All%20States&ngsLOB=DME&jurisdiction=Jurisdiction%20Bhttps://www.ngsmedicare.com/ngs/poc/ngsmedicare?1dmy&urile=wcm%3apath%3a%2FNGSMedicareContentNEW%2FNGSMedicareNEW%2FClaim%2BSubmission%2BArticles%2Band%2BModifier%2BTips%2FClaim%2BSubmission%2F2011%2BHCPCS%2BCode%2BUpdate_Revised&LOB=DME&LOC=All%20States&ngsLOC=All%20States&ngsLOB=DME&jurisdiction=Jurisdiction%20Bhttp://author.ngsmedicare.com/ngs/poc/ngsmedicare?1dmy&urile=wcm%3apath%3a%2FNGSMedicareContentNEW%2FNGSMedicareNEW%2FPolicy%2FLCDs%2Band%2BPolicy%2BArticles%2B-%2BMPC%2BContent%2FLCD%2Bfor%2BExternal%2BInfusion%2BPumps%2B%2528L33794%2529&LOB=DME&LOC=All%20States&ngsLOC=All%20States&ngsLOB=DME&jurisdiction=Jurisdiction%20Bhttp://author.ngsmedicare.com/ngs/poc/ngsmedicare?1dmy&urile=wcm%3apath%3a%2FNGSMedicareContentNEW%2FNGSMedicareNEW%2FPolicy%2FLCDs%2Band%2BPolicy%2BArticles%2B-%2BMPC%2BContent%2FLCD%2Bfro%2BIntravenous%2BImmune%2BGlobulin%2B%2528L33610%2529&LOB=DME&LOC=All%20States&ngsLOC=All%20States&ngsLOB=DME&jurisdiction=Jurisdiction%20Bhttp://author.ngsmedicare.com/ngs/poc/ngsmedicare?1dmy&urile=wcm%3apath%3a%2FNGSMedicareContentNEW%2FNGSMedicareNEW%2FPolicy%2FLCDs%2Band%2BPolicy%2BArticles%2B-%2BMPC%2BContent%2FLCD%2Bfor%2BNebulizers%2B%2528L33370%2529&LOB=DME&LOC=All%20States&ngsLOC=All%20States&ngsLOB=DME&jurisdiction=Jurisdiction%20Bhttps://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c17.pdfhttps://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c17.pdf


• The quantity administered is billed on one claim line without the JW modifier, and • The quantity discarded is billed on a separate claim line with the JW modifier

In this scenario, the JW modifier must be billed on a separate line to provide payment for the amount of discarded drug or biological. For example:

• A single use vial is labeled to contain 100 mg of a drug. • The drug’s HCPCS code UOS is 1 UOS = 1 mg. • 95 mg of the 100 mg in the vial are administered to the beneficiary. • 5 mg remaining in the vial are discarded. • The 95 mg dose is billed on one claim line as 95 UOS. • The discarded 5 mg is billed as 5 UOS on a separate claim line with the JW modifier. • Both claim line items would be processed for payment.

Scenario 2 When the HCPCS code UOS is equal to or greater than the total of the actual dose and the amount discarded, use of the JW modifier is not permitted. If the quantity of drug administered is less that a full UOS, the billed UOS is rounded to the appropriate UOS. For example:

• A single use vial is labeled to contain 100 mg of a drug. • The drug’s HCPCS code UOS is 1 UOS = 100 mg. • 70 mg of the 100 mg in the vial are administered to the beneficiary. • 30 mg remaining in the vial are discarded. • The 70 mg dose is billed correctly by rounding up to one UOS (representing the entire 100 mg vial) on

a single line item. • The single line item of 1 UOS would be processed for payment of the combined total 100 mg of

administered and discarded drug. • The discarded 30 mg must not be billed as another 1 UOS on a separate line item with the JW

modifier. Billing an additional 1 UOS for the discarded drug with the JW modifier is incorrect billing and will result in an overpayment.

Multi-use vials are not subject to payment for discarded amounts of drug or biological.

Claims for drugs billed to Medicare must use drug dosage formulations and/or unit dose sizes that minimize wastage. Providers and suppliers are expected to use drugs or biologicals most efficiently, in a clinically appropriate manner. Only when the most efficient combination of dosage forms are used and there is drug remaining may a supplier bill the discarded amount using the JW modifier on the claim line for the UOS not administered to the patient. Because of the HCPCS code descriptors and the associated UOS for DMEPOS items, the DME MACs expect rare use of the JW modifier on claims.

The JW modifier is used in conjunction with other modifiers listed in the applicable LCDs. For example, suppliers must add a JW modifier to codes for nebulizer drugs, in conjunction with the KX modifier, only if all of the criteria in the “Coverage Indications, Limitations and/or Medical Necessity” section of the Nebulizer LCD have been met.

Medicare Record Authentication – Tips for Physicians – Updated Note: This article updates Medicare Learning Network (MLN) Matters link and Medical Directors in a prior article “Medicare Record Authentication – Tips for Physicians” published on 7/15/2011.

http://author.ngsmedicare.com/ngs/poc/ngsmedicare?1dmy&urile=wcm%3apath%3a%2FNGSMedicareContentNEW%2FNGSMedicareNEW%2FPolicy%2FLCDs%2Band%2BPolicy%2BArticles%2B-%2BMPC%2BContent%2FLCD%2Bfor%2BNebulizers%2B%2528L33370%2529&LOB=DME&LOC=All%20States&ngsLOC=All%20States&ngsLOB=DME&jurisdiction=Jurisdiction%20B


Dear Physician,

Medicare requires that healthcare providers ordering or documenting the medical necessity for items or services received by Medicare beneficiaries must be identifiable. The Comprehensive Error Rate Testing (CERT) contractor notes that the majority of CERT errors are related to inability to identify the author of a medical record. Medical record authorship is generally accomplished through a handwritten or electronic signature (signature stamps are not acceptable); however, when the author of a record is unclear, document(s) must be authenticated. Signature logs or attestation statements are two acceptable methods to authenticate a record (excluding orders and Certificates of Medical Necessity [CMNs]).

Signature Logs Medicare contractors recommend that physicians consider preparing a single-page signature log or “key” to include when responding to requests for documentation. A signed and dated signature log identifies the author(s) associated with initials or “illegible” signatures within a set of medical records. When a physician’s office receives a request for copies of a beneficiary’s medical record, the signature log may then be included and returned to the requestor. This will help prevent follow-up contacts from suppliers and auditing entities for signature verification.

Attestation Statements In some cases, a medical record or entry omits a legible identifier requiring the author to attest to the authenticity of the record. To be considered valid for Medicare medical review purposes, an attestation statement must be signed and dated by the author of the medical record entry and must contain sufficient information to identify the beneficiary. Should a provider choose to submit an attestation statement, they may choose to use the following statement:

“I, _____[print full name of the physician/practitioner]___, hereby attest that the medical record entry for _____[date of service]___ accurately reflects signatures/notations that I made in my capacity as _____[insert provider credentials, e.g., M.D.]___ when I treated/diagnosed the above listed Medicare beneficiary. I do hereby attest that this information is true, accurate and complete to the best of my knowledge and I understand that any falsification, omission, or concealment of material fact may subject me to administrative, civil, or criminal liability.”

While this sample statement is an acceptable format, CMS is neither requiring nor instructing providers to use a certain form or format. The above format has not been approved by the Office of Management and Budget (OMB) and therefore it is not mandatory. Note that attestation statements are not valid for orders or CMNs where the author’s signature or initials are not authenticated. An overview of the key points of CMS’ signature requirements, including signature logs and attestation statements, can also be found in MLN Matters article MM6698.

Electronic Signatures Although the Centers for Medicare & Medicaid Services (CMS) has not published formal regulations regarding electronic signatures, Medicare contractors recommend that an electronic signature be accompanied by a statement indicating that the signature was applied electronically. Some examples of electronic signature notations include (not all-inclusive):

• Electronically signed by • Authenticated by • Approved by • Completed by • Finalized by • Signed by

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM6698.pdf


• Validated by • Sealed by

Notations such as those listed above indicate to the reviewer that the author’s name, typically applied in typed format, was electronically signed. Sincerely,

Paul J. Hughes, M.D. Medical Director, DME MAC, Jurisdiction A

Stacey V. Brennan, M.D., FAAFP Medical Director, DME MAC, Jurisdiction B

Robert D. Hoover, Jr., MD, MPH, FACP Medical Director, DME MAC, Jurisdiction C

Richard W. Whitten, MD, MBA Medical Director, DME MAC, Jurisdiction D

Appropriate Usage of the EX Modifier The CMS recently published Change Request 9468, “Payment for Purchased Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Furnished to Medicare Beneficiaries Residing Outside the U.S. - Expatriate Beneficiaries.” Per Change Request 9468, claims for DMEPOS item(s) provided to Medicare beneficiaries living outside of the United States (U.S.) are payable as long as the delivery occurred while the beneficiary was in the U.S. Proof of delivery documentation must support the item(s) was delivered to a U.S. address. P.O. boxes and lock boxes are not allowed for the proof of delivery of DMEPOS items for expatriate beneficiaries. Effective for date of service on or after 7/1/2016, the modifier EX was developed to allow suppliers to bill Medicare for purchased DMEPOS items that do not fall into one of the following categories:

• Oxygen equipment and supplies • Parenteral and enteral nutrition equipment and supplies • Capped rental items that do not have a purchase option • Inexpensive, routinely purchased items that are being rented • Mail order items including National Mail Order

Suppliers are to append the EX modifier (with all other applicable modifiers) to all claim lines. By appending the EX modifier, the supplier is attesting that the beneficiary is an expatriate beneficiary, the item was delivered/furnished while the beneficiary was present in the United States, and all other billing criteria have been met.

Suppliers who provide purchased DMEPOS items to expatriate beneficiaries are required to submit the claims to the Durable Medical Equipment Medicare Administrative Contractor jurisdiction based upon the locality of the billing supplier, not the beneficiary’s address. Suppliers must use the CMS-1500 paper claim form to bill Medicare for items provided to expatriate beneficiaries; claims submitted electronically will be rejected. Suppliers are not required to obtain an ASCA waiver to submit claims for expatriate beneficiaries.

Related Content • DME MAC Jurisdiction Map Jan 2016 • JB Supplier Manual

First Quarter 2016 Top Claim Submission Errors We conducted claim analysis for the first quarter of calendar year 2016 (January–March) of issues related to claim submission errors. Below is a chart listing the top claim submission errors as well as tips on how to reduce errors. The total denied claims for the first quarter was 665,217.

https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R3491CP.pdfhttps://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R3491CP.pdfhttps://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R3491CP.pdfhttps://www.cms.gov/Medicare/Medicare-Contracting/Medicare-Administrative-Contractors/Downloads/DME-MAC-Jurisdiction-Map-Jan-2016.pdfhttps://www.ngsmedicare.com/ngs/poc/ngsmedicare?1dmy&urile=wcm%3apath%3a%2FNGSMedicareContentNEW%2FNGSMedicareNEW%2FPublications%2FManuals%2FSupplierManual%2FChapter%2B8%2BDocumentation%2FProof%2Bof%2BDelivery%2BRequirements&LOB=&LOC=&ngsLOC=&ngsLOB=&jurisdiction=


ANSI Code

Category Denial Type January 2016

February 2016

March 2016

1st Quarter Total

% of Denials

16 Claim/service lacks information which is needed for adjudication.

Return/Reject 19,130 21,540 24,575 65,245 9.79%

4 The procedure code is inconsistent with the modifier used, or a required modifier is missing.

Return/Reject 16,034 17,074 19,123 52,231 7.85%

18 Duplicate Claim Duplicate 11,474 12,586 18,511 42,571 6.4%

176 Payment denied because the prescription is not current. Return/Reject 6,904 9,233 11,547 27,684 4.16%

24 Payment for charges adjusted. Charges covered under a capitation agreement/ managed care plan.

Eligibility 8,256 9,238 8,302 25,796 3.88%

A1 Claim/Service denied. Frequency 6,189 7,691 8,792 22,672 3.41%

151 Equipment is the same or similar to equipment already being used.

Same/Similar 7,171 6,947 7,959 22,077 3.32%

173 Payment adjusted because this service was not prescribed by a physician.

Return/Reject 4,098 5,283 6,008 15,389 2.31%

175 Payment denied because the prescription was incomplete

Return/Reject 2,443 2,694 5,732 10,869 1.63%

13 The date of death precedes the date of service. Return/Reject 2,486 2,635 3,049 9,268 1.23%


1. ANSI Reason Code – 16: Claim/service lacks information which is needed for adjudication

Claims were submitted to the Jurisdiction B Durable Medical Equipment Medicare Administrative Contractor (DME MAC) that contained incomplete or invalid information and cannot be processed as submitted. Please refer to the remark code (REM) on the remittance advice (RA). The REM code advises what information is missing or incomplete on the claim. If the REM field is not complete, suppliers may contact the Provider Contact Center to request additional information regarding the American National Standards Institute (ANSI)-16 rejection. We have received an increase in the volume of claims submitted without a required modifier or with an invalid modifier. You are reminded to use the KX, GA, GZ or GY modifier to indicate whether the coverage criteria are or are not met as outlined in the local medical policy. Since the KX modifier has a differing definition depending on the local coverage determination (LCD) requirements, you should review the LCDs carefully to understand the proper use of the KX, GA, GZ or GY modifiers for each policy. The LCDs and policy articles may be accessed through our website by selecting the Policy tab, then click the Medical Policy Center link. Claims denied with ANSI-16 are not eligible for an appeal or a reopening. The rejected claim must be resubmitted with the missing/incomplete information.

2. ANSI Reason Code – 4: The procedure code is inconsistent with the modifier used, or a required modifier is missing

For a complete listing of the Healthcare Common Procedure Coding System (HCPCS) modifiers, please consult the Jurisdiction B (JB) Supplier Manual, Chapter 14 “Level II HCPCS Codes and HCPCS Modifiers.” Additionally, specific instructions regarding modifier usage is located in the JB Supplier Manual, Chapter 15, “DMEPOS Payment Categories.” The LCDs and policy articles provide specific instructions for using the informational modifiers listed within the medical policy. Medical policies can be accessed from the Medical Policy Center section of our website.

You may also utilize the DME Coding System (DMECS), to verify if the HCPCS code requires a primary pricing modifier. DMECS provides HCPCS coding assistance and national pricing information via searches for HCPCS Level II codes and modifiers, DMEPOS items and Centers for Medicare & Medicaid Services (CMS) national fee schedules. To search for HCPCS and modifier coding or to find out more about the DMECS, please visit the Pricing, Data Analysis, and Coding Contractor’s website.

3. ANSI Reason Code – 18: Duplicate claims

We receive a large quantity of claims that result in duplicate denials. The duplicate claim submission denial is the number-one claims submission error. Generally, claim submission errors are services/items previously processed for the same patient, date of service and HCPCS code.

You are reminded to allow 14 days for electronically submitted claims and 29 days for hard copy claims before resubmitting a claim to the DME MAC. You should utilize the Claim Status Inquiry (CSI), NGSConnex or the interactive voice response (IVR) system at 877-299-7900 before resubmitting the claim for payment

4. ANSI Reason Code – 176: Payment denied because the prescription is not current

We encourage you to review the medical policies, referred to as LCDs, to verify whether or not an initial, revised or recertification Certificate of Medical Necessity (CMN) is required for a specific item. When submitting claims that require a CMN, you should ensure that all sections of the CMN are completed prior to submitting the claim to the DME MAC. You should submit the CMN with the initial claim only, and wait 24–48 hours before submitting any subsequent claims. The LCDs can be found in the

http://www.ngsmedicare.com/ngs/portal/ngsmedicare/0614%20first%20quarter%202014%20supplier%20telephone%20inquiries/%21ut/p/a1/xVLJTsMwEP2VXHqM7CaOmx6jllR0RS0VjS_IcZzUVeosdhDw9TgFBAe6QA_4YPnNvBnPzBtAwAYQSZ9ERrUoJM1bTPAjHK8GQeghCGd9CG8DvApHI-giHxlCdJywmDvn4h8AAYRJXeotiGSm9jwRjNacFVJzqTvwm60DyybOzbMtTnXgrqmFMq4WWrFlQiRnHz6Iu8hKRa20VTW01ry2HGhMqinLXBikec7LbSG5JWTViFpw1ZZS0ownXIlMHhATCYgY6rm0z1wbuYiZy09tH_axjbppgin3HRzHn4M4cgJ43SDD3pVCeBcJcUbKd8KJFk9maHs4_YUHItNF74uwGIVDQ-hOPWe9vL8bYrD6pSzjC-bm1LPBLGu111tbyLQAmz-tj0kldlVFArPR7fo-a7D575Uen9Ps5_5jqrh1vBhQ7td7f5dOJlO8vEnnc5vEL-7rNHgDagP_Uw%21%21/dl5/d5/L2dBISEvZ0FBIS9nQSEh/?1dmy&urile=wcm%3apath%3a%2Fngsmedicarecontent%2Fngsmedicare%2Fcoverage%2Bdetermination%2Fmedical%2Bpolicy%2Bcenterhttp://author.ngsmedicare.com/ngs/poc/ngsmedicare?1dmy&urile=wcm%3apath%3a%2FNGSMedicareContentNEW%2FNGSMedicareNEW%2FPublications%2FManuals%2FSupplierManual%2FChapter%2B14%2B-%2BLevel%2BII%2BHCPCS%2BCodes%2Band%2BHCPCS%2BModifiers%2FLevel%2BII%2BHCPCS%2BCodes&LOB=DME&LOC=All%20States&ngsLOC=All%20States&ngsLOB=DME&jurisdiction=Jurisdiction%20Bhttp://author.ngsmedicare.com/ngs/poc/ngsmedicare?1dmy&urile=wcm%3apath%3a%2FNGSMedicareContentNEW%2FNGSMedicareNEW%2FPublications%2FManuals%2FSupplierManual%2FChapter%2B14%2B-%2BLevel%2BII%2BHCPCS%2BCodes%2Band%2BHCPCS%2BModifiers%2FLevel%2BII%2BHCPCS%2BCodes&LOB=DME&LOC=All%20States&ngsLOC=All%20States&ngsLOB=DME&jurisdiction=Jurisdiction%20Bhttp://author.ngsmedicare.com/ngs/poc/ngsmedicare?1dmy&urile=wcm%3apath%3a%2FNGSMedicareContentNEW%2FNGSMedicareNEW%2FPublications%2FManuals%2FSupplierManual%2FChapter%2B15%2B-%2BDurable%2BMedical%2BEquipment%252C%2BProsthetics%252C%2BOrthotics%252C%2Band%2BSupplies%2BPayment%2BCategories%2FDMEPOS%2BPayment%2BCategories%2BOverview&LOB=DME&LOC=All%20States&ngsLOC=All%20States&ngsLOB=DME&jurisdiction=Jurisdiction%20Bhttp://author.ngsmedicare.com/ngs/poc/ngsmedicare?1dmy&urile=wcm%3apath%3a%2FNGSMedicareContentNEW%2FNGSMedicareNEW%2FPublications%2FManuals%2FSupplierManual%2FChapter%2B15%2B-%2BDurable%2BMedical%2BEquipment%252C%2BProsthetics%252C%2BOrthotics%252C%2Band%2BSupplies%2BPayment%2BCategories%2FDMEPOS%2BPayment%2BCategories%2BOverview&LOB=DME&LOC=All%20States&ngsLOC=All%20States&ngsLOB=DME&jurisdiction=Jurisdiction%20Bhttp://www.ngsmedicare.com/ngs/portal/ngsmedicare/0614%20first%20quarter%202014%20supplier%20telephone%20inquiries/%21ut/p/a1/xVLJTsMwEP2VXHqM7CaOmx6jllR0RS0VjS_IcZzUVeosdhDw9TgFBAe6QA_4YPnNvBnPzBtAwAYQSZ9ERrUoJM1bTPAjHK8GQeghCGd9CG8DvApHI-giHxlCdJywmDvn4h8AAYRJXeotiGSm9jwRjNacFVJzqTvwm60DyybOzbMtTnXgrqmFMq4WWrFlQiRnHz6Iu8hKRa20VTW01ry2HGhMqinLXBikec7LbSG5JWTViFpw1ZZS0ownXIlMHhATCYgY6rm0z1wbuYiZy09tH_axjbppgin3HRzHn4M4cgJ43SDD3pVCeBcJcUbKd8KJFk9maHs4_YUHItNF74uwGIVDQ-hOPWe9vL8bYrD6pSzjC-bm1LPBLGu111tbyLQAmz-tj0kldlVFArPR7fo-a7D575Uen9Ps5_5jqrh1vBhQ7td7f5dOJlO8vEnnc5vEL-7rNHgDagP_Uw%21%21/dl5/d5/L2dBISEvZ0FBIS9nQSEh/?1dmy&urile=wcm%3apath%3a%2Fngsmedicarecontent%2Fngsmedicare%2Fcoverage%2Bdetermination%2Fmedical%2Bpolicy%2Bcenterhttps://www.dmepdac.com/contact/index.htmlhttp://author.ngsmedicare.com/ngs/poc/ngsmedicare?1dmy&urile=wcm%3apath%3a%2FNGSMedicareContentNEW%2FNGSMedicareNEW%2FElectronic%2BData%2BInterchange%2FElectronic%2BData%2BInterchange%2FTask%2B1_DME&LOB=DME&LOC=All%20States&ngsLOC=All%20States&ngsLOB=DME&jurisdiction=Jurisdiction%20Bhttp://www.ngsconnex.com/http://author.ngsmedicare.com/ngs/poc/ngsmedicare?uri=wcm:path:&page=Z6_4AIE11C0K0SRC0AK6R2V911006&LOB=DME&LOC=All%20States&ngsLOC=All%20States&ngsLOB=DME&jurisdiction=Jurisdiction%20B


However, if a claim denies because the patient has previously received same/similar equipment, and you were unaware of the previous purchase, you should refund the beneficiary or exercise his/her appeal rights and request a redetermination. Redetermination requests may be submitted to the following address:

Jurisdiction B DME MAC Redeterminations P.O. Box 6036 Indianapolis, IN 46206-6036

You may also fax redetermination requests. You should complete the Medicare DME Redetermination Request Form and fax the redetermination request to 317-595-4737.

You also have the option to submit redetermination requests via a secure Internet portal called NGSConnex. Access to NGSConnex only requires users to have the Internet and an email address. There are no costs associated with using this application. For additional information regarding NGSConnex, suppliers should login to the NGSConnex application.

5. ANSI Reason Code – 24: Payment for charges adjusted. Charges are covered under a capitation agreement/managed care plan

Our records indicate that the beneficiary is enrolled in a Medicare Advantage plan, often referred to as a health maintenance organization (HMO). If the beneficiary elects to receive his or her Medicare benefits through a managed care plan, the beneficiary usually is required to receive all his or her care from doctors, hospitals, and other health care providers that are part of the plan. Beneficiaries enrolled in a Medicare HMO will receive an identification card from their Medicare HMO. Beneficiaries, doctors, hospitals, or any other health care provider must contact the HMO for details pertaining to coverage requirements. The DME MACs do not process claims for Medicare HMOs. You must submit your claim to the appropriate insurance carrier for the specific HMO in which the beneficiary is enrolled. We encourage you to utilize the IVR system or NGSConnex for assistance in determining whether the beneficiary is enrolled in a Medicare Advantage Plan/HMO.

By selecting Option 2 from the main menu of the IVR, you will be able to obtain the Medicare HMO number, name, address, telephone number and effective/termination date of the plan. The IVR system is available from 7:00 a.m.–6:00 p.m. eastern time (ET), Monday through Friday, and 7:00 a.m.–3:00 p.m. most Saturdays. You may access the IVR system by dialing 877-299-7900. For additional information regarding the IVR system, you should refer to the IVR user guide located on our website.

Online eligibility is available through the free, online application NGSConnex. NGSConnex offers you superior search capabilities that will help make it fast and easy for you to find the information you seek without having to place calls to our Provider Contact Center.

6. ANSI Reason Code – A1: Claim/service denied

Our records indicate that the billing exceeds the rental months for oxygen. You may utilize NGSConnex or the IVR system at 877-299-7900 to determine if the beneficiary’s record indicates there are 36 rentals on file for oxygen.

7. ANSI Reason Code – 151: Equipment is the same or similar to equipment already being used

You should evaluate the patient’s history during the intake process to determine if the same or similar equipment was previously obtained. You may utilize CSI, NGSConnex or the IVR system at 877-299-7900 to determine if the beneficiary’s record indicates they already has the same/similar equipment. If the beneficiary wants the same/similar equipment and agrees to be financially liable, the supplier should have

http://author.ngsmedicare.com/ngs/wcm/connect/dd57b5a6-51c0-4f51-bf2b-9d0f760594e9/305_dme_redetermination_0812.pdf?MOD=AJPEREShttp://author.ngsmedicare.com/ngs/wcm/connect/dd57b5a6-51c0-4f51-bf2b-9d0f760594e9/305_dme_redetermination_0812.pdf?MOD=AJPEREShttp://www.ngsconnex.com/http://author.ngsmedicare.com/ngs/poc/ngsmedicare?uri=wcm:path:&page=Z6_4AIE11C0K0SRC0AK6R2V911006&LOB=DME&LOC=All%20States&ngsLOC=All%20States&ngsLOB=DME&jurisdiction=Jurisdiction%20Bhttp://author.ngsmedicare.com/ngs/poc/ngsmedicare?uri=wcm:path:&page=Z6_4AIE11C0K0SRC0AK6R2V911006&LOB=DME&LOC=All%20States&ngsLOC=All%20States&ngsLOB=DME&jurisdiction=Jurisdiction%20Bhttp://www.ngsconnex.com/http://author.ngsmedicare.com/ngs/poc/ngsmedicare?uri=wcm:path:&page=Z6_4AIE11C0K0SRC0AK6R2V911006&LOB=DME&LOC=All%20States&ngsLOC=All%20States&ngsLOB=DME&jurisdiction=Jurisdiction%20Bhttp://author.ngsmedicare.com/ngs/wcm/connect/90be9740-152f-4db5-bc9d-323ce257d06f/906_0815_dme_ivr_user_guide_508.pdf?MOD=AJPEREShttp://www.ngsconnex.com/http://www.ngsconnex.com/http://author.ngsmedicare.com/ngs/poc/ngsmedicare?uri=wcm:path:&page=Z6_4AIE11C0K0SRC0AK6R2V911006&LOB=DME&LOC=All%20States&ngsLOC=All%20States&ngsLOB=DME&jurisdiction=Jurisdiction%20Bhttp://author.ngsmedicare.com/ngs/poc/ngsmedicare?1dmy&urile=wcm%3apath%3a%2FNGSMedicareContentNEW%2FNGSMedicareNEW%2FElectronic%2BData%2BInterchange%2FElectronic%2BData%2BInterchange%2FTask%2B1_DME&LOB=DME&LOC=All%20States&ngsLOC=All%20States&ngsLOB=DME&jurisdiction=Jurisdiction%20Bhttp://www.ngsconnex.com/http://author.ngsmedicare.com/ngs/poc/ngsmedicare?uri=wcm:path:&page=Z6_4AIE11C0K0SRC0AK6R2V911006&LOB=DME&LOC=All%20States&ngsLOC=All%20States&ngsLOB=DME&jurisdiction=Jurisdiction%20B


the beneficiary sign an Advance Beneficiary Notice of Noncoverage (ABN) and submit the claim with modifier GA to indicate an ABN is on file. However, if a claim denies because the patient has previously received the same/similar equipment, and the supplier was unaware of the previous purchase, the supplier should refund the beneficiary (if applicable). You may choose to exercise their right to request a redetermination. Redetermination requests may be submitted to the following address:

Redeterminations P.O. Box 6036 Indianapolis, IN 46206-6036

You may also fax redetermination requests. You should complete the Medicare DME Redetermination Request Form and fax the redetermination request to 317-595-4737.

You also have the option to submit redetermination requests via a secure Internet portal called NGSConnex. Access to NGSConnex only requires users to have the Internet and an email address. There are no costs associated with using this application. For additional information regarding NGSConnex, you should login to the NGSConnex application.

8. ANSI Reason Code – 173: Payment adjusted because this service was not prescribed by a physician

We encourage you to review medical policies to verify whether or not the items or services routinely provided to Medicare beneficiaries require an initial, revised or recertification CMN. When submitting claims that require a CMN, you should ensure that all sections of the CMN are completed prior to claim submission to the DME MAC. You should submit the CMN with the initial claim only and wait 24–48 hours before submitting any subsequent claims. The medical policies are located within the Medical Policy Center section of our website.

9. ANSI Reason Code – 175: Payment denied because the prescription was incomplete

We encourage you to review medical policies to verify whether or not the items or services routinely provided to Medicare beneficiaries require an initial, revised or recertification CMN or a DIF. When submitting claims that require a CMN or a DIF, you should ensure that all sections of the CMN and DIF are completed prior to claim submission to the DME MAC. You should submit the CMN and/or DIF with the initial claim only and wait 24–48 hours before submitting any subsequent claims. The medical policies are located within the Medical Policy Center section of our website.

10. ANSI Reason Code – 13: The date of death precedes the date of service

Medicare Part B coverage was not valid when the patient received this item and/or service. Expenses were incurred after coverage was terminated, prior to coverage, date of death precedes the date of service or Medicare was unable to identify the patient as an insured. You should contact the beneficiary to whom they are providing service, to determine whether the beneficiary is still using the supplier’s equipment. We also recommended that you check your patients’ Health Insurance Claim card and Medicare records for valid coverage dates and for correct patient information prior to claim submission.

http://www.ngsconnex.com/http://author.ngsmedicare.com/ngs/poc/ngsmedicare?uri=wcm:path:&page=Z6_4AIE11C0KOD170AK4P0HTO0G95&LOB=DME&LOC=All%20States&ngsLOC=All%20States&ngsLOB=DME&jurisdiction=Jurisdiction%20Bhttp://author.ngsmedicare.com/ngs/poc/ngsmedicare?uri=wcm:path:&page=Z6_4AIE11C0KOD170AK4P0HTO0G95&LOB=DME&LOC=All%20States&ngsLOC=All%20States&ngsLOB=DME&jurisdiction=Jurisdiction%20Bhttp://author.ngsmedicare.com/ngs/poc/ngsmedicare?uri=wcm:path:&page=Z6_4AIE11C0KOD170AK4P0HTO0G95&LOB=DME&LOC=All%20States&ngsLOC=All%20States&ngsLOB=DME&jurisdiction=Jurisdiction%20B


FEE SCHEDULE, PRICING AND OVERPAYMENTS New Extended Repayment Schedule – Voluntary Underpayment Form The Centers for Medicare & Medicaid Services Change Request 9423 created a new form, Extended Repayment Schedule – Voluntary Underpayment Form, which allows you to apply future underpayments to the debts for which an extended repayment schedule (ERS) was requested.

The new form can be found on our Extended Repayment Plans web page.

Hassle-Free Timesaver – Submit Immediate Recoupment Requests Online Are you still faxing your immediate recoupment request forms? Faxing these forms can cause lengthy delays in processing due to the potential for multiple transmission errors. Choose the hassle-free way and save time by electronically submitting your request via our website. Follow the steps below to electronically submit an Immediate Recoupment Request Form.

1. Visit the Jurisdiction B DME website.

• Either “Sign In” or “Continue as A Guest” Please note that if you frequent our site as a Guest user and bill more than just DME (i.e. Medicare Part A and B), you may need to click the National Government Services logo in the upper left-hand corner to reset your contract selection.

• When choosing the “Continue as A Guest” option, you will need to select “DME Supplier” in the “I am a…” drop-down box, as this selection will later determine which electronic form you complete and where it will be routed.

2. Once on the Jurisdiction B – DME Welcome page, click on the Supplier Resources tab, and then select Forms.

https://www.ngsmedicare.com/ngs/wcm/connect/ff644547-c6b1-4094-92c7-fce7d34dae7c/513_0316_dmemac_ers_documentation_request_form_508.pdf?MOD=AJPEREShttps://www.ngsmedicare.com/ngs/wcm/connect/ff644547-c6b1-4094-92c7-fce7d34dae7c/513_0316_dmemac_ers_documentation_request_form_508.pdf?MOD=AJPEREShttps://www.ngsmedicare.com/ngs/portal/ngsmedicare/newngs/home-lob/news-alerts/news-articles/news-detail/new%20extended%20repayment%20schedule%20-%20voluntary%20underpayment%20form/%21ut/p/a1/vVLLcoIwFP0VXHSZSRAEXUZBaq3PjqOwcSIJSIXAhKi1X99gtbULazudaVb3nJyb-ziBAVzAgJNdEhOZ5JykFQ6spYl7rq53UH_UvEcI9x1s4qFnNGc6nMMABiXZsTDPNwmrUJgyIj7h1PV6o-HxgstCrqHP4zJjNAmJUFlcMi4529-hC_ods30JCKeApEzI8kwImagKCp5yj7zGXlRMGdUEK8ghU7xWhmtGtynTgLbL0y2XRBy0rRKJsyLKRVY1VoQJhX6dWLZlWRTYSLeBaekGWBGzAeo21VurBo1a7DjQ46gNfWfgquX4ajnoysHoR7v7IjFGTYTNbttxJmPDa9dPgm9K-KoH-2oRXYdP1RvzzmA5mblTpb7wSqFLrxQ8eaWijyF_t54b7Rj_3M7DTQvaShGYlocrN-ti0BnEqgKRa5DwKIeLv_2tIttMvaaRgQV6bhQxdl6jLMN4PARBN8a12hu-J1uc/dl5/d5/L2dBISEvZ0FBIS9nQSEh/?1dmy&urile=wcm%3apath%3a%2Fngsmedicarecontentnew%2Fngsmedicarenew%2Foverpayment%2Fdme_extended%2Brepayment%2Bplanshttps://www.ngsmedicare.com/


3. Select the Overpayments button on the Forms menu.

Then select the overpayment form titled “Immediate Recoupment Request Form – Electronic/E-mail”

Complete the form in its entirety, agree with the terms, and click Submit.

Congratulations, you did it! The next time you visit our website to complete an Immediate Recoupment Request Form – Electronic/E-mail, be sure to follow all the appropriate steps listed above to ensure you are visiting as a DME supplier.

MEDICAL POLICY Local Coverage Determination and Policy Article Revisions Summary for 5/19/2016 Outlined below are the principal changes to DME MAC local coverage determinations (LCDs) and a policy article (PA) that have been revised and posted. The policies included are glucose monitors and knee orthoses. Please review the entire LCDs and related PA for complete information.

Glucose Monitors LCD Revision Effective Date: 05/30/2016 HCPCS CODES: Removed: A9276, A9277, A9278

https://www.ngsmedicare.com/ngs/portal/ngsmedicare/newngs/home-lob/news-alerts/news-articles/news-detail/hassle-free%20timesaver%20-%20submit%20immediate%20recoupment%20requests%20online/%21ut/p/a1/vVJNc4IwEP0rePCYSRBEPEZBaq2fHUfh4kQMmEoCJVFn-usbrG3twdrOdJrTvs3uvpd9gRFcwkiQA0uJYrkgWYUjZ2Xjvm-aXTQYu3cI4YGHbTwKLHduwgWMYCTJgcZ5vmO0QnFGSfkJZ37QH49OF0IVagtDkUpONywmpe4Sigol6LGOLtJvmB4lIGIDSEZLJd8TpWKaQcNzbx1tiZQZBUlJqaEYp5Wc0gCG3K85Uwbj1ViiqFHx7Quum3T4vKdSSSMXGRMnoUXMNjAklmknzQ0CzVaCgG3GbbB2HAsQkrTseN02XSeuqh_GHRh6Q1-vKNQrQlcORj_a4JcSa-wibPc6njedWEGncS74hiLUGlpXSUwTPlYzFt3hajr3Z7r6wjGNLh3T8OyYjj4e-bv13JBj_bOc-5sW6IlRZDsBrtxslMPuMNUMRG0BE0kOl3_xwwq-mwWuxcESPTWLFHsvCecYT0Yg6qW4VnsFLgxM0g%21%21/dl5/d5/L2dBISEvZ0FBIS9nQSEh/?1dmy&urile=wcm%3apath%3a%2Fngsmedicarecontentnew%2Fngsmedicarenew%2Fsupplier%2Bor%2Bprovider%2Bresources%2Fforms%2Fimmediate%2Brecoupment%2Brequest%2Bform-electronice-mailhttps://www.ngsmedicare.com/ngs/poc/ngsmedicare?uri=wcm:path:&page=Z6_4AIE11C0KOD170AK4P0HTO0G95&LOB=DME&LOC=All%20States&ngsLOC=All%20States&ngsLOB=DME&jurisdiction=Jurisdiction%20B


Knee Orthoses LCD Revision Effective Date: 06/02/2016 ICD-10 CODES THAT SUPPORT MEDICAL NECESSITY: Added: HCPCS Codes L1832 and L1833 to Group 2 Diagnoses Added: Initial, Subsequent, and Sequela ICD-10s to Group 2 and Group 4 Removed: ICD-10 Non-specific femur codes S72.426B & S72.426C – entered in error DOCUMENTATION REQUIREMENTS: Revised: Standard Documentation language (Effective 04/28/2016) ICD-10 CODES THAT SUPPORT MEDICAL NECESSITY: Added: HCPCS Codes L1832 and L1833 to Group 2 Diagnoses Added: Initial, Subsequent, and Sequela ICD-10s to Group 2 and Group 4 Removed: ICD-10 Non-specific femur codes S72.426B & S72.426C – entered in error DOCUMENTATION REQUIREMENTS: Revised: Standard Documentation language (Effective 04/28/2016)

Policy Article Revision Effective Date: 06/02/2016 NON-MEDICAL NECESSITY COVERAGE AND PAYMENT RULES: Added: Definitions from CMS DMEPOS Quality Standards (42 CFR 424.57) and 42 CFR 414.402 CODING GUIDELINES: Added: Custom fabricated orthosis definitions Added: Definition of K0672

Note: The information contained in this article is only a summary of revisions to the LCDs and PA. For complete information on any topic, you must review the LCDs and/or PA.

Local Coverage Determinations and Policy Article Revisions Summary for 3/3/2016 Outlined below are the principal changes to Durable Medical Equipment Medicare Administrative Contractors (DME MAC) local coverage determinations (LCDs) and policy articles (PAs) that have been revised and posted. The policies included are ankle-foot/knee-ankle-foot orthosis, bowel management devices, external infusion pumps, immunosuppressive drugs, oral antiemetic drugs (replacement for intravenous antiemetics), parenteral nutrition, respiratory assist devices and wheelchair options/accessories. Please review the entire LCD and related PA for complete information.

Ankle-Foot/Knee-Ankle-Foot Orthosis LCD Revision Effective Date: 01/01/2016: COVERAGE INDICATIONS, LIMITATIONS AND/OR MEDICAL NECESSITY: Added: L4361 “clerical correction” HCPCS CODES: Revised: L1902 and L1904 long narrative description DOCUMENTATION REQUIREMENTS: Revised: Standard Documentation Language to remove start date verbiage from Prescription Requirements (Effective 11/5/2015) Moved: Repair/Replacement verbiage to correct location Updated: Miscellaneous section when billing L2999

https://www.ngsmedicare.com/ngs/poc/ngsmedicare?uri=wcm:path:&page=Z6_4AIE11C0KOD170AK4P0HTO0G95&LOB=DME&LOC=All%20States&ngsLOC=All%20States&ngsLOB=DME&jurisdiction=Jurisdiction%20Bhttps://www.ngsmedicare.com/ngs/portal/ngsmedicare/newngs/home-lob/news-alerts/news-articles/news-detail/local%20coverage%20determinations%20and%20policy%20article%20revisions%20summary%20for%20332016/%21ut/p/a1/vVLLcoIwFP0VXLjMJAgILqNYai0-x1HYOBECpkJgQqpjv77B2tYurO1Mp1nl3NzHuecEhnAFQ072LCWSFZxkNQ7baxMP-rreQ8Oxc48QHrrYxCPPcBY6XMIQhhXZ06godozWKMooEZ9w1vcG49HpgctSbmHA0yqnMYuIUFVcUi45PTTRRfgN00MFCI8ByaiQ1XtASKYmKHiubaKsiEimRcWeCpJSLaaSipzx0w6VpjpoZZGx6KidazVB96w6PVbPeU7EUUsKoRlGC-ntmmgZsRgG5sa2UGwhYNm2CcyE2oAkiQ1i1IkdFEeoYzl19uO4CwPX7yuxAiUWunIw-pGWX1KMsYOwedd13enE8Lqtc8I3IwLFwb46RNfhvO6x7Pnr6aI_U9kX3il06Z2CZ-_U7WPJ38lzg47xz3QeblmgLGwJv-enqi2RW8B4UsDV336wpQvDue22twdY5ruZ5xg5WKEnq0yx-5LkOcaTEQg3R9xovAKYPPiS/dl5/d5/L2dBISEvZ0FBIS9nQSEh/?1dmy&urile=wcm%3apath%3a%2Fngsmedicarecontentnew%2Fngsmedicarenew%2Fpolicy%2Fmedical%2Bpolicy%2Bcenter%2B-%2Blanding%2Bpages%2Fdme%2Bmpc%2B-%2Bactive


Policy Article Revision Effective Date: 01/01/2016 CODING GUIDELINES: Added: L4361 “clerical correction”

Bowel Management Devices LCD Revision Effective Date: 01/01/2016 COVERAGE INDICATIONS, INDICATIONS, LIMITATIONS AND/OR MEDICAL NECESSITY: Replaced: Miscellaneous HCPCS Code A4335 with new code A4337 HCPCS CODES: Added: HCPCS Code A4337 DOCUMENTATION REQUIREMENTS: Revised: Standard Documentation language to remove start date verbiage from Prescription Requirements (Effective 11/05/2015)

Policy Article Revision Effective Date: 01/01/2016 CODING GUIDELINES: Replaced: Miscellaneous HCPCS Code A4335 with new code A4337

External Infusion Pumps LCD Revision Effective Date: 01/01/2016 COVERAGE INDICATIONS, INDICATIONS, LIMITATIONS AND/OR MEDICAL NECESSITY: Added: HCPCS CODE J1575 to Subcutaneous immune globulin coverage Added: HCPCS CODE J7340 to Levodopa-Carbidopa coverage Added: HCPCS CODE J9039 to Blinatumomab coverage Updated: HCPCS Code Q9977 crosswalked to J7999 HCPCS CODES: Group 3 Codes: Added: HCPCS Code J1575, J7340, J9039 (previously J7799) Deleted: HCPCS Code Q9977 ICD-10 CODES THAT SUPPORT MEDICAL NECESSITY: Group 3 Codes: Added: ICD-10 Code D83.1 to Group 3 Codes Group 3 Paragraph: Added: HCPCS Code J1575 Group 4 Paragraph: Added: HCPCS Code J7340 Group 5 Paragraph: Added: HCPCS Code J9039 DOCUMENTATION REQUIREMENTS: Revised: Standard Documentation language to remove start date verbiage from Prescription Requirements (Effective 11/5/2015)

Policy Article Revision Effective Date: 01/01/2016 NON-MEDICAL NECESSITY COVERAGE AND PAYMENT RULES:


Revised: Standard Documentation Language to remove start date verbiage from Prescription Requirements (Effective 11/5/2015) CODING GUIDELINES: Updated: HCPCS Code Q9977 cross-walked to J7999 Added: J1575, J7340, J9039 (previously J7799) Updated: Billing instructions, by HCPCS code, based on dates of service

Immunosuppressive Drugs LCD Revision Effective Date: 01/01/2016 HCPCS CODES: Added: J7503 and J7512 Updated: J7508 narrative Deleted: J7506 DOCUMENTATION REQUIREMENTS: Revised: Standard Documentation Language to remove start date verbiage from Prescription Requirements (Effective 11/5/2015)

Policy Article Revision Effective Dates: 01/01/2016 CODING GUIDELINES: Removed: J7506 from billing example, replaced with J7510

Oral Antiemetic Drugs (Replacement for Intravenous Antiemetics) LCD Revision Effective Date: 01/01/2016 COVERAGE INDICATIONS, LIMITATIONS, AND/OR MEDICAL NECESSITY: Updated: 3-drug regimen billing instructions HCPCS CODES: Added: HCPCS code J8655 Deleted: HCPCS code Q9978 DOCUMENTATION REQUIREMENTS: Revised: Standard Documentation Language to remove start date verbiage from Prescription Requirements (Effective 11/5/2015) POLICY SPECIFIC DOCUMENTATION REQUIREMENTS: Added: J8655 to modifier billing instructions Added: End date for HCPCS code Q9975 Added: Q0181 for billing rolapitant on or after 09/02/2015 KX, GA AND GZ MODIFIERS: Added: Rolapitant (Q0181) to guidelines Added: J8655 to guidelines

Policy Article Revision Effective Date: 01/01/2016 NON-MEDICAL NECESSITY COVERAGE AND PAYMENT RULES: Revised: Covered 3-drug combination regimen CODING GUIDELINES: Added: J8655


Added: End date of 12/31/2015 for Q9978 Added: Q0181 for billing rolapitant effective on or after 09/02/2015

Parenteral Nutrition LCD Revision Effective Date: 01/01/2016 HCPCS CODES: Group 1 codes: Updated: HCPCS Code B5000, B5100, B5200 narrative description DOCUMENTATION REQUIREMENTS: Revised: Standard Documentation language to remove start date verbiage from Prescription Requirements (Effective 11/05/2015)

Policy Article Removed: Effective Date from Policy Article title

Respiratory Assist Devices LCD Revision Effective Date: 01/01/2016 COVERAGE INDICATIONS, LIMITATIONS AND/OR MEDICAL NECESSITY: Replaced: HCPCS Codes E0450, E0460-E0464 with new HCPCS Codes E0465, E0466 DOCUMENTATION REQUIREMENTS Revised: Standard Documentation language to remove start date verbiage from Prescription Requirements (Effective 11/05/2015)

Policy Article Revision Effective Date: 11/05/2015 NON-MEDICAL NECESSITY COVERAGE AND PAYMENT RULES: Revised: Standard Documentation language to remove start date verbiage from Prescription Requirements

Wheelchair Options/Accessories LCD Revision Effective Date: 01/01/2016 COVERAGE INDICATIONS, LIMITATIONS AND/OR MEDICAL NECESSITY: Added: HCPCS code E1012 to Power Tilt and/or Recline Seating Systems range HCPCS CODES: Added: HCPCS code E1012 Revised: K0017 and K0018 long narrative description DOCUMENTATION REQUIREMENTS: Revised: Standard Documentation Language to remove start date verbiage from Prescription Requirements (Effective 11/5/2015)

Policy Article Revision Effective Date: 01/01/2016 NON-MEDICAL NECESSITY COVERAGE AND PAYMENT RULES: Revised: Standard Documentation Language to remove start date verbiage from Prescription Requirements (Effective 11/5/2015)


CODING GUIDELINES: Added: HCPCS code E1012 Added: HCPCS code E1012 to bundling table

Note: The information contained in this article is only a summary of revisions to the LCD and PA. For complete information on any topic, you must review the LCD and/or PA.

Local Coverage Determination and Policy Article Revisions Summary for 3/17/2016 Outlined below are the principal changes to Durable Medical Equipment Medicare Administrative Contractor (DME MAC) local coverage determinations (LCDs) and policy articles (PAs) that have been revised and posted. Please review the entire LCD and related PA for complete information.

Urological Supplies LCD Revision Effective Date: 01/01/2016 COVERAGE INDICATIONS, LIMITATIONS AND/OR MEDICAL NECESSITY: Added: Non-reimbursement language for the inFlow™ Intraurethral Valve-Pump system (A4335) DOCUMENTATION REQUIREMENTS: Revised: Standard Documentation Language to remove start date verbiage from Prescription Requirements (Effective 11/05/2015)

Policy Article Revision Effective Date: 01/01/2016 CODING GUIDELINES: Added: Coding guidelines for the inFlow™ Intraurethral Valve-Pump (A4335)

Note: The information contained in this article is only a summary of revisions to LCD and PA. For complete information on any topic, you must review the LCD and/or PA.

MISCELLANEOUS SUPPLIER INFORMATION CMS Website Links In April 2012, the Centers for Medicare & Medicaid Services (CMS) underwent a website migration which in turn changed their website URLs. Temporary redirects were put in place and are still in place at this time. As of July 1, 2016, CMS will retire all redirects. You will need to update all saved CMS hyperlinks, bookmarks and website favorites prior to July 1 to ensure continued access to CMS.gov.

Round 2 Recompete and National Mail-Order Recompete Contract Suppliers Announced On April 28, Centers for Medicare & Medicaid Services (CMS) announced the contract suppliers for Round 2 Recompete and the national mail-order recompete of the Medicare Durable Medical Equipment, Prosthetics, Orthotics, and Supplies Competitive Bidding Program. These contracts will begin on July 1.

A list of Round 2 Recompete and the national mail-order recompete contract supplier locations for each product category and competitive bidding area is now available on the Competitive Bidding Implementation Contractor (CBIC) website. This list is current as of April 28, 2016. Contract suppliers may add or change

https://www.ngsmedicare.com/ngs/portal/ngsmedicare/newngs/home-lob/news-alerts/news-articles/news-detail/local%20coverage%20determinations%20and%20policy%20article%20revisions%20summary%20for%20332016/%21ut/p/a1/vVLLcoIwFP0VXLjMJAgILqNYai0-x1HYOBECpkJgQqpjv77B2tYurO1Mp1nl3NzHuecEhnAFQ072LCWSFZxkNQ7baxMP-rreQ8Oxc48QHrrYxCPPcBY6XMIQhhXZ06godozWKMooEZ9w1vcG49HpgctSbmHA0yqnMYuIUFVcUi45PTTRRfgN00MFCI8ByaiQ1XtASKYmKHiubaKsiEimRcWeCpJSLaaSipzx0w6VpjpoZZGx6KidazVB96w6PVbPeU7EUUsKoRlGC-ntmmgZsRgG5sa2UGwhYNm2CcyE2oAkiQ1i1IkdFEeoYzl19uO4CwPX7yuxAiUWunIw-pGWX1KMsYOwedd13enE8Lqtc8I3IwLFwb46RNfhvO6x7Pnr6aI_U9kX3il06Z2CZ-_U7WPJ38lzg47xz3QeblmgLGwJv-enqi2RW8B4UsDV336wpQvDue22twdY5ruZ5xg5WKEnq0yx-5LkOcaTEQg3R9xovAKYPPiS/dl5/d5/L2dBISEvZ0FBIS9nQSEh/?1dmy&urile=wcm%3apath%3a%2Fngsmedicarecontentnew%2Fngsmedicarenew%2Fpolicy%2Fmedical%2Bpolicy%2Bcenter%2B-%2Blanding%2Bpages%2Fdme%2Bmpc%2B-%2Bactivehttps://www.ngsmedicare.com/ngs/portal/ngsmedicare/newngs/home-lob/news-alerts/news-articles/news-detail/local%20coverage%20determination%20and%20policy%20article%20revisions%20summary%20for%203172016/%21ut/p/a1/vVLLUsMgFP0VXLhkgJC-lrSptda0to7TJhsHCU3RBDIE69Svl2jVuvA148iKc7mPc88BpWiFUs23KudOGc2LBqft65CNh4QM8GTWPcWYTSIWsumIdq8IWqIUpTXfSmHMnZINEoXk9h0uhqPxbPr8oF3lNijReV3KTAlufZV2UjstH47xQfgFy4cacp1BXkjr6teAdcpP8HBfe4wLI3gBhNlKy3MJMumkLZV-3gH4BqAyhRI7sC8FVm5V7d9qUN-XJbc7sDYWUNIJMGk3RCuhMpRkghAStnuwF4gAhrLVhjygHZjRkAS9HhU8aDXZ57M-SqJ46MVKvFj4k8Pwj7T8kEJnXczCk34UzS_oqB_sE74YkXgOnU-HEIIumx7LQXw9vxoufPaBdx4deufh3jt_e1vyd_J8Q4f-M52z7yzwFgY2HsS5b8vdBiq9Nmj1tx9seYLSeGMmY4aq8m4x6tISrvBtq8pZ9LguS8YupjC92bGjoydMBmlv/dl5/d5/L2dBISEvZ0FBIS9nQSEh/?1dmy&urile=wcm%3apath%3a%2Fngsmedicarecontentnew%2Fngsmedicarenew%2Fpolicy%2Flcds%2Band%2Bpolicy%2Barticles%2B-%2Bmpc%2Bcontent%2Flcd%2Bfor%2Burological%2Bsupplies%2B%2528l33803%2529https://www.ngsmedicare.com/ngs/portal/ngsmedicare/newngs/home-lob/news-alerts/news-articles/news-detail/local%20coverage%20determination%20and%20policy%20article%20revisions%20summary%20for%203172016/%21ut/p/a1/vVLLUsMgFP0VXLhkgJC-lrSptda0to7TJhsHCU3RBDIE69Svl2jVuvA148iKc7mPc88BpWiFUs23KudOGc2LBqft65CNh4QM8GTWPcWYTSIWsumIdq8IWqIUpTXfSmHMnZINEoXk9h0uhqPxbPr8oF3lNijReV3KTAlufZV2UjstH47xQfgFy4cacp1BXkjr6teAdcpP8HBfe4wLI3gBhNlKy3MJMumkLZV-3gH4BqAyhRI7sC8FVm5V7d9qUN-XJbc7sDYWUNIJMGk3RCuhMpRkghAStnuwF4gAhrLVhjygHZjRkAS9HhU8aDXZ57M-SqJ46MVKvFj4k8Pwj7T8kEJnXczCk34UzS_oqB_sE74YkXgOnU-HEIIumx7LQXw9vxoufPaBdx4deufh3jt_e1vyd_J8Q4f-M52z7yzwFgY2HsS5b8vdBiq9Nmj1tx9seYLSeGMmY4aq8m4x6tISrvBtq8pZ9LguS8YupjC92bGjoydMBmlv/dl5/d5/L2dBISEvZ0FBIS9nQSEh/?1dmy&urile=wcm%3apath%3a%2Fngsmedicarecontentnew%2Fngsmedicarenew%2Fpolicy%2Flcds%2Band%2Bpolicy%2Barticles%2B-%2Bmpc%2Bcontent%2Furological%2Bsupplies%2B-%2Bpolicy%2Barticle%2B-%2Beffective%2Boctober%2B2015%2B%2528a52521%2529https://www.ngsmedicare.com/ngs/portal/ngsmedicare/newngs/home-lob/news-alerts/news-articles/news-detail/local%20coverage%20determination%20and%20policy%20article%20revisions%20summary%20for%203172016/%21ut/p/a1/vVLLUsMgFP0VXLhkgJC-lrSptda0to7TJhsHCU3RBDIE69Svl2jVuvA148iKc7mPc88BpWiFUs23KudOGc2LBqft65CNh4QM8GTWPcWYTSIWsumIdq8IWqIUpTXfSmHMnZINEoXk9h0uhqPxbPr8oF3lNijReV3KTAlufZV2UjstH47xQfgFy4cacp1BXkjr6teAdcpP8HBfe4wLI3gBhNlKy3MJMumkLZV-3gH4BqAyhRI7sC8FVm5V7d9qUN-XJbc7sDYWUNIJMGk3RCuhMpRkghAStnuwF4gAhrLVhjygHZjRkAS9HhU8aDXZ57M-SqJ46MVKvFj4k8Pwj7T8kEJnXczCk34UzS_oqB_sE74YkXgOnU-HEIIumx7LQXw9vxoufPaBdx4deufh3jt_e1vyd_J8Q4f-M52z7yzwFgY2HsS5b8vdBiq9Nmj1tx9seYLSeGMmY4aq8m4x6tISrvBtq8pZ9LguS8YupjC92bGjoydMBmlv/dl5/d5/L2dBISEvZ0FBIS9nQSEh/?1dmy&urile=wcm%3apath%3a%2Fngsmedicarecontentnew%2Fngsmedicarenew%2Fpolicy%2Flcds%2Band%2Bpolicy%2Barticles%2B-%2Bmpc%2Bcontent%2Flcd%2Bfor%2Burological%2Bsupplies%2B%2528l33803%2529https://www.ngsmedicare.com/ngs/portal/ngsmedicare/newngs/home-lob/news-alerts/news-articles/news-detail/local%20coverage%20determination%20and%20policy%20article%20revisions%20summary%20for%203172016/%21ut/p/a1/vVLLUsMgFP0VXLhkgJC-lrSptda0to7TJhsHCU3RBDIE69Svl2jVuvA148iKc7mPc88BpWiFUs23KudOGc2LBqft65CNh4QM8GTWPcWYTSIWsumIdq8IWqIUpTXfSmHMnZINEoXk9h0uhqPxbPr8oF3lNijReV3KTAlufZV2UjstH47xQfgFy4cacp1BXkjr6teAdcpP8HBfe4wLI3gBhNlKy3MJMumkLZV-3gH4BqAyhRI7sC8FVm5V7d9qUN-XJbc7sDYWUNIJMGk3RCuhMpRkghAStnuwF4gAhrLVhjygHZjRkAS9HhU8aDXZ57M-SqJ46MVKvFj4k8Pwj7T8kEJnXczCk34UzS_oqB_sE74YkXgOnU-HEIIumx7LQXw9vxoufPaBdx4deufh3jt_e1vyd_J8Q4f-M52z7yzwFgY2HsS5b8vdBiq9Nmj1tx9seYLSeGMmY4aq8m4x6tISrvBtq8pZ9LguS8YupjC92bGjoydMBmlv/dl5/d5/L2dBISEvZ0FBIS9nQSEh/?1dmy&urile=wcm%3apath%3a%2Fngsmedicarecontentnew%2Fngsmedicarenew%2Fpolicy%2Flcds%2Band%2Bpolicy%2Barticles%2B-%2Bmpc%2Bcontent%2Furological%2Bsupplies%2B-%2Bpolicy%2Barticle%2B-%2Beffective%2Boctober%2B2015%2B%2528a52521%2529http://www.dmecompetitivebid.com/palmetto/cbicrd2recompete.nsf/docsCat/Round%202%20Recompete%7EContract%20Suppliers%7EContract%20Supplier%20Locations?open&expand=1&navmenu=Contract%5eSuppliers||http://www.dmecompetitivebid.com/palmetto/cbicrd2recompete.nsf/docsCat/Round%202%20Recompete%7EContract%20Suppliers%7EContract%20Supplier%20Locations?open&expand=1&navmenu=Contract%5eSuppliers||


locations on their competitive bidding contract. Updates to the Medicare Supplier Directory will be posted in mid-June 2016.

For more information, view the fact sheet.

Comprehensive Error Rate Testing Documentation Contractor Updates The Comprehensive Error Rate Testing (CERT) Documentation Contractor (DC) is responsible for requesting and receiving the medical record documentation from providers. Within the next several weeks the CERT DC will be making changes to their website that will make it easier for suppliers to obtain information on documentation requests.

The site will include the following:

• An alphabetical listing for each provider type and billing type • Providers will be able to view and print their Documentation Request Listing

– If printed, you should refer to the CERT Provider website to confirm the current documentation request listing.

• Documentation descriptions will be available in both English and Spanish • Documentation Request Listings will be updated when changes are approved.

Remember, if you respond to a documentation request and submit documentation via CD, you should send the password to [email protected] and include the CID number in the subject line of the email. You do not need to encrypt the email. If you follow this procedure it will ensure that there is no delay in processing the documentation.

Comprehensive Error Rate Testing High Error Audit – First Quarter 2016 Widespread Prepayment Review Update Jurisdiction B continues to conduct a widespread prepayment medical review of Comprehensive Error Rate Testing (CERT) high error audit claims.

Between 1/1/2016 and 3/31/2016, our Medical Review Department performed a complex review of 3250 claims. A total of 1501 claims were allowed and 1749 claims were denied, resulting in a claim error rate of 53.82 percent. A total of 269 claims were denied because documentation was not received in a timely manner.

Quarter Claims Reviewed Claims Error Rate 2Q2015 4,546 65.58%

3Q2015 3,352 58.35%

4Q2015 4329 52.46%

1Q2016 3250 53.82%

Data collected during the first quarter identified the top denial reasons as:

Nutrition Claims • The proof of delivery record did not include the delivery service’s package identification number,

supplier invoice number or alternative method that links the supplier’s delivery documents with the delivery service’s records

https://www.medicare.gov/supplierdirectory/https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2016-Fact-sheets-items/2016-04-28.htmlhttps://www.certprovider.com/https://www.certprovider.com/mailto:[email protected]


• No required documentation to justify the medical need of the item billed • The proof of delivery record did not include evidence of delivery • The benefit for service(s) is included in the payment/allowance for another service/procedure that has

already been adjudicated • No documentation to support the beneficiary had a covered situation from policy article A47126

prosthetic benefit requirements section to allow coverage for parenteral nutrition Prosthetic and Orthotic Claims • Healthcare Common Procedure Coding System (HCPCS) code(s) is not payable • No medical records were submitted • No documentation from the treating physician to support the beneficiary’s potential functional level • Insufficient information from the treating physician, either on order or in the medical record, regarding

physiological changes of the beneficiary resulting in the need for a replacement • No information about the beneficiary’s history and current condition which supports the designation of

the functional level by the prosthetist Power Mobility Device Claims • The specialty evaluation did not provide detailed information explaining why each specific option or

accessory is needed to address the beneficiary’s mobility limitation • The documentation does not support the physical or functional deficits to justify the medical necessity

for the option/accessory • The option/accessory is a noncovered item • The detailed product description does not contain the HCPCS code that is billed on the claim • The face-to-face examination requires a date stamp (or equivalent) to document the receipt date of the

examination by the supplier Drug Claims • No medical records were submitted • The refill request was not obtained and documented before shipment • The detailed written order did not include a physician signature that complied with the Centers for

Medicare & Medicaid Services (CMS) signature requirements outlined in CMS Internet-Only Manual (IOM) Medicare Program Integrity Manual, 3.3.2.4. and signature date

• The detailed written order was not submitted • The shipping date did not match the date of service on the claim for a shipping service or mail order by

the supplier Negative Pressure Wound Therapy Pump Claims • Supplier-produced records, even if signed by the ordering physician, and attestation letters are deemed

not to be part of a medical record for Medicare payment purposes • For ulcers and wounds, no documentation of an evaluation of and provision for adequate nutritional

status • No evidence of a licensed medical professional on at least a monthly basis, documented changes in

the ulcer’s dimensions and characteristics • No evidence of wound therapy program was tried or considered and ruled out prior to application of

negative pressure wound therapy • No evidence of a licensed medical professional supervised or directly performed the negative pressure

wound therapy dressing changes Surgical Dressing Claims • Incorrect use of modifier • Documentation does not support more frequent evaluation for heavily draining wound.

https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/pim83c03.pdfhttps://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/pim83c03.pdf


• Order did not specify quantity to be used at one time • Invoice and items billed do not match • Wound debridement was not seen in the document

Claims submitted from multiple suppliers were identified for review. Additional documentation was requested and the documentation received was reviewed to assure that all coverage criteria and documentation requirements were met. Based on the above results and findings, we will continue to monitor.

You are reminded that failure to respond to requests for additional documentation is in violation of supplier standard number 28, found in the Centers for Medicare & Medicaid Services (CMS) Internet-Only Manual (IOM) Publication 100-08, Medicare Program Integrity Manual, Chapter 15, which states “Under 42 CFR §424.516(f)(1), a provider or supplier that furnishes covered ordered items of durable medical equipment, prosthetics, orthotics and supplies (DMEPOS), clinical laboratory, imaging services, or covered ordered/certified home health services is required to maintain documentation for 7 years from the date of service, and upon the request of CMS or a Medicare contractor, provide access to that documentation.”

You can quickly obtain additional details about the reason for a complex or noncomplex medical review denial view by using the Medical Review Denial Tool, which is available on the our website. To use the tool, enter the 14-digit claim control number (CCN) from your remittance advice, in the CCN form field and select Submit. Select Reset to enter information for a new CCN. The Medical Review Denial Tool is available on our website under Supplier Resources, then Calculations & Tools.

To help avoid errors and ensure that you are appropriately and properly reimbursed under Medicare, you should visit our website to obtain valuable educational resources.

Related Content • Calculators & Tools • JB Supplier Manual • Medical Policy Center • Medical Review Focus Areas • Medicare University Course List • Policy Education Topics

Notice of New Interest Rates for Medicare Overpayments and Underpayments – Change Request 9644 Effective 4/19/2016, the new interest rate for Medicare overpayments and underpayments is 10.00 percent. The interest rates on overpayments and underpayments is determined in accordance with regulations promulgated by the Secretary of the Treasury and is the higher of the private consumer rate or the current value of funds rate prevailing on the date of final determination. Interest accrues from the date of the initial request for refund and is assessed for each 30-day period, or portion thereof, that payment is delayed after the initial refund request.

Interest assessed for both late payments and installment payments is computed as simple interest using a 360-day year. Simple interest is interest that is paid on the original principal balance and after each payment interest accrues on the remaining unpaid principal balance. Interest charges will not be prorated on a daily basis for overdue payments received during the month (e.g., 10, 15 or 20 days late). Interest is assessed for the full 30-day period. The interest rate on each of the final determinations will be the rate in effect on the date the determination is made.

http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/pim83c15.pdfhttp://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/pim83c15.pdfhttps://www.ngsmedicare.com/ngs/portal/ngsmedicare/mrdenialtoolhttps://www.ngsmedicare.com/ngs/portal/ngsmedicare/mrdenialtoolhttps://www.ngsmedicare.com/ngs/portal/ngsmedicare/newngs/home-lob/pages/complianceandaudits/medical-review/medical-review-focus-areas/medical-review-focus-areas-detail/enteral%20nutrition%20-%20fourth%20quarter%202015%20widespread%20prepayment%20review%20update/%21ut/p/a1/vVLdboIwGH2V7gGall_xsgoSnYhgnMKNKVKwUX5WwWU-_Uq2OW-cW7KsF03O19PvnJ5-KEZrFJf0xHPa8Kqkhw7H5kYnY0dRhvjRnYwNTBbzYPmkhwoOTLRCMYqP9MS2VbXnrEPbA6PiC4aOO_ZnKBqhmKjnxA66Yr3lKYr6mkl1k2XQ0g0V6lijMOmlfWhhrGn9JDEpwx176g9QZHuOtBNJO_jGIvhHbq8pvuZbmOijgW0Hc80dqB-EbyQi6aF3U8TDaPHLB95pqL43XA29TbB0Qsm-ilui67gl_IwbRZfU_tSO8s92Jnf_1L0MlhwPVXhDL5cKtNlBXmYVWrOyYYIeQNk2gndzDSDIqlY0O_DcUiEPgYoVA7zwlB1rwWgK5F7T10LeBIKdOHsBbZ3ShqG62IdOcs6mZmhhzahzYp-zoiBkPoPxKH94A8t10FE%21/dl5/d5/L2dBISEvZ0FBIS9nQSEh/?1dmy&urile=wcm%3apath%3a%2Fngsmedicarecontentnew%2Fngsmedicarenew%2Fsupplier%2Bor%2Bprovider%2Bresources%2Fcalculators%2Band%2Btools%2Findexhttps://www.ngsmedicare.com/ngs/portal/ngsmedicare/newngs/home-lob/pages/complianceandaudits/medical-review/medical-review-focus-areas/medical-review-focus-areas-detail/enteral%20nutrition%20-%20fourth%20quarter%202015%20widespread%20prepayment%20review%20update/%21ut/p/a1/vVLdboIwGH2V7gGall_xsgoSnYhgnMKNKVKwUX5WwWU-_Uq2OW-cW7KsF03O19PvnJ5-KEZrFJf0xHPa8Kqkhw7H5kYnY0dRhvjRnYwNTBbzYPmkhwoOTLRCMYqP9MS2VbXnrEPbA6PiC4aOO_ZnKBqhmKjnxA66Yr3lKYr6mkl1k2XQ0g0V6lijMOmlfWhhrGn9JDEpwx176g9QZHuOtBNJO_jGIvhHbq8pvuZbmOijgW0Hc80dqB-EbyQi6aF3U8TDaPHLB95pqL43XA29TbB0Qsm-ilui67gl_IwbRZfU_tSO8s92Jnf_1L0MlhwPVXhDL5cKtNlBXmYVWrOyYYIeQNk2gndzDSDIqlY0O_DcUiEPgYoVA7zwlB1rwWgK5F7T10LeBIKdOHsBbZ3ShqG62IdOcs6mZmhhzahzYp-zoiBkPoPxKH94A8t10FE%21/dl5/d5/L2dBISEvZ0FBIS9nQSEh/?1dmy&urile=wcm%3apath%3a%2Fngsmedicarecontentnew%2Fngsmedicarenew%2Fpublications%2Fmanuals%2Fsuppliermanual%2Fforeword%2Fabout%2Bthe%2Bsupplier%2Bmanualhttps://www.ngsmedicare.com/ngs/portal/ngsmedicare/newngs/home-lob/pages/complianceandaudits/medical-review/medical-review-focus-areas/medical-review-focus-areas-detail/enteral%20nutrition%20-%20fourth%20quarter%202015%20widespread%20prepayment%20review%20update/%21ut/p/a1/vVLdboIwGH2V7gGall_xsgoSnYhgnMKNKVKwUX5WwWU-_Uq2OW-cW7KsF03O19PvnJ5-KEZrFJf0xHPa8Kqkhw7H5kYnY0dRhvjRnYwNTBbzYPmkhwoOTLRCMYqP9MS2VbXnrEPbA6PiC4aOO_ZnKBqhmKjnxA66Yr3lKYr6mkl1k2XQ0g0V6lijMOmlfWhhrGn9JDEpwx176g9QZHuOtBNJO_jGIvhHbq8pvuZbmOijgW0Hc80dqB-EbyQi6aF3U8TDaPHLB95pqL43XA29TbB0Qsm-ilui67gl_IwbRZfU_tSO8s92Jnf_1L0MlhwPVXhDL5cKtNlBXmYVWrOyYYIeQNk2gndzDSDIqlY0O_DcUiEPgYoVA7zwlB1rwWgK5F7T10LeBIKdOHsBbZ3ShqG62IdOcs6mZmhhzahzYp-zoiBkPoPxKH94A8t10FE%21/dl5/d5/L2dBISEvZ0FBIS9nQSEh/?1dmy&urile=wcm%3apath%3a%2Fngsmedicarecontentnew%2Fngsmedicarenew%2Fpolicy%2Fmedical%2Bpolicy%2Bcenter%2B-%2Blanding%2Bpages%2Fbase%2Bmedicare%2Bcoverage%2Bdatabasehttps://www.ngsmedicare.com/ngs/portal/ngsmedicare/newngs/home-lob/pages/complianceandaudits/medical-review/medical-review-focus-areas/medical-review-focus-areas-detail/enteral%20nutrition%20-%20fourth%20quarter%202015%20widespread%20prepayment%20review%20update/%21ut/p/a1/vVLdboIwGH2V7gGall_xsgoSnYhgnMKNKVKwUX5WwWU-_Uq2OW-cW7KsF03O19PvnJ5-KEZrFJf0xHPa8Kqkhw7H5kYnY0dRhvjRnYwNTBbzYPmkhwoOTLRCMYqP9MS2VbXnrEPbA6PiC4aOO_ZnKBqhmKjnxA66Yr3lKYr6mkl1k2XQ0g0V6lijMOmlfWhhrGn9JDEpwx176g9QZHuOtBNJO_jGIvhHbq8pvuZbmOijgW0Hc80dqB-EbyQi6aF3U8TDaPHLB95pqL43XA29TbB0Qsm-ilui67gl_IwbRZfU_tSO8s92Jnf_1L0MlhwPVXhDL5cKtNlBXmYVWrOyYYIeQNk2gndzDSDIqlY0O_DcUiEPgYoVA7zwlB1rwWgK5F7T10LeBIKdOHsBbZ3ShqG62IdOcs6mZmhhzahzYp-zoiBkPoPxKH94A8t10FE%21/dl5/d5/L2dBISEvZ0FBIS9nQSEh/?1dmy&urile=wcm%3apath%3a%2Fngsmedicarecontentnew%2Fngsmedicarenew%2Fcompliance%2Band%2Baudits%2Fmedical%2Breview%2Fmedical%2Breview%2Bfocus%2Bareas%2B%2528landing%2Bpages%2529%2Fdme_dmeposhttps://www.ngsmedicare.com/ngs/portal/ngsmedicare/newngs/home-lob/pages/complianceandaudits/medical-review/medical-review-focus-areas/medical-review-focus-areas-detail/enteral%20nutrition%20-%20fourth%20quarter%202015%20widespread%20prepayment%20review%20update/%21ut/p/a1/vVLdboIwGH2V7gGall_xsgoSnYhgnMKNKVKwUX5WwWU-_Uq2OW-cW7KsF03O19PvnJ5-KEZrFJf0xHPa8Kqkhw7H5kYnY0dRhvjRnYwNTBbzYPmkhwoOTLRCMYqP9MS2VbXnrEPbA6PiC4aOO_ZnKBqhmKjnxA66Yr3lKYr6mkl1k2XQ0g0V6lijMOmlfWhhrGn9JDEpwx176g9QZHuOtBNJO_jGIvhHbq8pvuZbmOijgW0Hc80dqB-EbyQi6aF3U8TDaPHLB95pqL43XA29TbB0Qsm-ilui67gl_IwbRZfU_tSO8s92Jnf_1L0MlhwPVXhDL5cKtNlBXmYVWrOyYYIeQNk2gndzDSDIqlY0O_DcUiEPgYoVA7zwlB1rwWgK5F7T10LeBIKdOHsBbZ3ShqG62IdOcs6mZmhhzahzYp-zoiBkPoPxKH94A8t10FE%21/dl5/d5/L2dBISEvZ0FBIS9nQSEh/?1dmy&urile=wcm%3apath%3a%2Fngsmedicarecontentnew%2Fngsmedicarenew%2Ftraining%2Fmedicare%2Buniversity%2Fmu%2Bcourse%2Blist%2Fdme_mu%2Bcourse%2Blisthttps://www.ngsmedicare.com/ngs/portal/ngsmedicare/newngs/home-lob/pages/complianceandaudits/medical-review/medical-review-focus-areas/medical-revie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Period Rate Interest January 17, 2013–April 16, 2013 10.625% April 17, 2013–July 16, 2013 10.125% July 17, 2013–October 17, 2013 10.375% October 18, 2013–January 20, 2014 10.125% January 21, 2014–April 16, 2014 10.25% April 17, 2014–July 17, 2014 10.125% July 18, 2014–October 19, 2014 9.625% October 20, 2014–January 20, 2015 10.75% January 21, 2015–April 16, 2015 10.5% April 17, 2015–October 19, 2015 9.875% October 20, 2015–January 18, 2016 10.00% January 19, 2016–April 18, 2016 9.75% April 19, 2016 10.00%

Comprehensive Error Rate Testing High-Error Audit – Fourth Quarter 2015 Widespread Prepayment Review Update Jurisdiction B continues to conduct a widespread prepayment medical review of Comprehensive Error Rate Testing (CERT) high-error audit claims.

Between 10/1/2015 and 12/31/2015, our Medical Review Department performed a complex review of 4,329 claims. A total of 2,058 claims were allowed and 2,271 claims were denied, resulting in a claim error rate of 52.46 percent. A total of 321 claims were denied because documentation was not received in a timely manner.

Quarter Claims Reviewed Claims Error Rate 1Q2015 5,400 61.41% 2Q2015 4,546 65.58% 3Q2015 3,352 58.35% 4Q2015 4,329 52.46%

Data collected during the fourth quarter identified the top denial reasons as:

Nutrition Claims • The refill request documentation was not received. • The date the beneficiary received the durable medical equipment prosthetics, orthotics and supplies

(DMEPOS) supply delivered directly by the supplier did not match the date of service on the claim. • No required documentation to justify the medical need of the item billed. • No documentation to support the beneficiary had a covered situation from policy article A47126

Prosthetic Benefit Requirements section to allow coverage for parenteral nutrition.

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Jurisdiction B Connections - CGS Medicare · 2017. 11. 28. · Pressure Reducing Support Surfaces...

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